Rujukan Umum Baru

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PEMERINTAH KOTA TASIKMALAYA

UPTD PUSKESMAS TAWANG

Jl. Pancasila No. 17 Tlp. (0265) 7523699
E-mail : puskesmastawangcitra17@gmail.com
TASIKMALAYA
Kode Pos 46111
=======================================================================
RUJUKAN UMUM

NO ……/ PKM//20….

Kepada :

Yth………………………………………………

…………………………………………………..

Mohon Tindakan dan pengobatan selanjutnya :

Nama : …………………………………………………………………………………

Umur : …………………………………………………………………………………

Alamat : …………………………………………………………………………………

Keluhan : …………………………………………………………………………………

Diagnosa : …………………………………………………………………………………

Terima kasih atas perhatian dan kerjasamanya.

Tasikmalaya, ……………………………….

Salam Sejawat,

(…………………………………)

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